Clinical Documentation Specialist

Mosaic
Joseph, MO Other | Full Time
POSTED ON 8/29/2024 CLOSED ON 9/7/2024

What are the responsibilities and job description for the Clinical Documentation Specialist position at Mosaic?

Mosaic Life Care is a health care system in northwest Missouri. With a vision of transforming community health by being a life-care innovator, Mosaic places the holistic needs of patients first by providing the right care at the right time and place, offering high value and quality health care.

Mosaic has a wide array of benefits to meet each employee’s individual needs. Our benefits were designed by listening to people just like you. Mosaic also offers several perks with a focus on ensuring our employees feel valued, including concierge services, employee lounge, wellness programs, free covered parking, free on-site and virtual health clinics and many more. When paired with compensation and recognition, it is what continues to make us the employer of choice for employees at any stage of their journey.

Details
  • Clinical Documentation Specialist
  • Inpatient Coding 
  • Full Time Status
  • Day Shift
  • Pay: $54766.40 - $87630.40 / year 
Summary
  • This position provides support, consultation, compliance to evidence-based care, and clinical documentation practices. Facilitates and drives improvements in the clinical performance initiatives and helps to maintain regulatory compliant documentation. Performance relies on general nursing/clinical knowledge, including pathophysiology, pharmacology, regulatory requirements and ACDIS professional guidelines. Advanced communication and education to a broad audience including medical staff, patients, clinical departments in the form of specific chart reviews and broad presentation/education.  Collaborates regarding clinical and coding knowledge with key stakeholders within the organization. Responsibilities include concurrent review of the clinical documentation to obtain the most accurate and complete physician documentation that appropriately supports the severity of illness, risk of mortality and proper reimbursement.
  • This position works under the supervision of the Manager and is employed by Mosaic Health Systems.
Duties
  • Conducts initial concurrent review and ongoing re-reviews of clinical documentation for all selected admissions to initiate the tracking process and document findings.
  • Assigns and updates working DRG for encounters, reviewing in a timely manner and documenting thoroughly in clinical documentation improvement system.
  • Identifies need to clarify documentation in records and initiates communication with physician or physician extender utilizing the appropriate query tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness.
  • Utilizes monitoring tools to track the progress of the concurrent review program, interprets tracking information and reports findings.
  • Provides information and education as necessary to physicians and ancillary staff. This includes participation on work teams.
  • Other duties as assigned
Qualifications
  •  All required education is a minimum requirement. Higher levels of education are acceptable. Associate's Degree nursing required. Bachelor's Degree nursing preferred.
  • RN  - Registered Nurse - State Licensure And/Or Compact State Licensure in state, depending upon designated work location is required. AND CCDS Certification - Certificated Clinical Documentation Specialist to be obtained within two years of hire is required. OR CDIP Certification - Certified Documentation Information Practitioner to be obtained within two years of hire required.
  • 3 Years- Clinical experience in an ICU/Critical Care acute care setting is required. 1 year experience in clinical documentation integrity functions is preferred.

Salary : $54,766 - $87,630

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